Fourmile Veterinary Clinic - Client Information Form

Client Information

Please complete the following information for our medical records. Thank you for giving Fourmile Veterinary Clinic the opportunity to care for your pets.
Owner Information
Name*

First NameLast Name
Client Birthday*

MonthDayYear
Date
Cell Phone*
Home Phone
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Place of Employment
Work Phone
Please enter a valid phone number.
Spouse Information
Spouse's Name

First NameLast Name
Spouse's Birthdate
Spouse's Email
example@example.com
Spouse's Cell Phone
Please enter a valid phone number.
Spouse's Place of Employment
Spouse's Work Phone
Please enter a valid phone number.
Additional Contacts
Relative/Friend Name*
Relative/Friend Home Phone
Please enter a valid phone number.
Relative/Friend Cell Phone*
Please enter a valid phone number.
Relative/Friend Name
Relative/Friend Home Phone
Please enter a valid phone number.
Relative/Friend Cell Phone
Please enter a valid phone number.
How did you choose our clinic?*

I was referredPhone BookOther
If referral, who can we thank?*
Payment Policy

Please have your driver's license available for ID and processing your payment
Full payment is due at the time of the appointment. We do not charge.

We accept cash, debit cards, MasterCard, Vise, Discover, and checks. Returned checks are electronically debited from your account for the amount of check plus a returned check fee of $20.00. FINANCE CHARGE is 1.5% per month (18% annually) interest accrues on unpaid balances 30 days past due, $5.00 monthly statement mailing fee. You are liable for all attorny fees and costs if collections proceeding are required. I understand that I will be responsible for payment of all fees incurred in the collect of the unpaid balance.

If payment cannot be made, please notify the receptionist so we can reschedule the appointment at a more convenient time for you.

Authorization:

I hereby authorize the veterinarian to examine, prescribe for, and treat my pets. I assume resonsibility for all charges incurred in the care of my animals. I also understand that these charges will be paid at the time of service and that a deposit may be required for treatment.
Signature*

Clear
Date*

MonthDayYear
Date
To be completed by office staff:
DL full name
DL address
DL state
DL #
DOB
HT
WT
Hair
Eye
DL full name
DL address
DL state
DL #
DOB
HT
WT
Hair
Eye
Should be Empty:

Client Information

Owner Information

Spouse Information

Additional Contacts

Payment Policy

To be completed by office staff: